A nurse is caring for a toddler who is 24 hr postoperative following a cleft palate repair.
Which of the following actions should the nurse take?
Apply bilateral wrist restraints.
Implement a soft diet.
Administer opioids for pain.
Offer fluids through a straw.
The Correct Answer is C
A. Applying bilateral wrist restraints is not a standard intervention after cleft palate repair.
Restraints should be used judiciously and with clear indications to prevent injury.
B. The baby can start feeding normal diet after 24hrs
C. Administering opioids for pain is an appropriate action by the nurse. Opioids control pain in the immediate postoperative period are followed by administration of acetaminophen PRN.
D. Offering fluids through a straw is contraindicated after cleft palate repair, as it can disrupt the healing process and increase the risk of complications. Sippy cups or other appropriate utensils should be used.
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Related Questions
Correct Answer is B
Explanation
A. A respiratory rate of 20/min is within the normal range, and while it should be monitored, it is not the priority in this case.
B. Blood pressure is a critical indicator of perfusion and can be affected by internal bleeding or other serious injuries. A low blood pressure may suggest significant blood loss and is the priority in assessing for shock.
C. A heart rate of 72/min is within the normal range for an adolescent. While it should be monitored, it is not the immediate priority.
D. Abdominal pain is a subjective measure and, while important, may not accurately reflect the severity of internal injuries. The priority is to assess the hemodynamic stability, as indicated by blood pressure.
Correct Answer is C
Explanation
A. Cromolyn sodium is a preventive medication for asthma, but it is not typically used at the first sign of breathing difficulty.
B. The peak expiratory flow meter should be used regularly to monitor asthma control, not just once per week.
C. Avoiding triggers that cause an asthma attack is a crucial aspect of asthma management.
Identifying and minimizing exposure to triggers help prevent exacerbations.
D. Exercise is important for overall health, and many individuals with asthma can participate in physical activities, including basketball. The nurse should encourage the child to discuss appropriate physical activities with the healthcare provider.
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